Should Doctors Advice Patients to Switch to E-cigarettes?

Should Doctors Advice Patients to Switch to E-cigarettes?

Introduction

Electronic cigarettes (henceforth referred to as e-cigarettes or e-cigars) have been proposed and supported by ethicists, healthcare experts, policymakers, social workers, and the public in general as effective remedies to combat traditional cigarette smoking and its associated health and social problems. Health experts cite the health benefits of non-combustible e-cigarettes in eliminating toxins associated with the combustion of traditional cigarettes. Similarly, utilitarian ethicists cite e-cigarettes benefits in cutting down healthcare costs associated with the multitude of health and social problems associated with traditional cigarette smoking. Some policymakers and general public concur with utilitarian ethicists in supporting e-cigarette as a feasible means of plugging healthcare budget deficit (Fairchild et al. 216). Despite realist benefits of e-cigarette in mitigating health and social problems associated with cigarette smoking and in control of healthcare budget deficits, evidence-based research and randomly controlled trials reveal similar cytotoxicity threat of e-cigarettes to human health as that posed by traditional cigarette smoking. In particular, random controlled studies of e-cigarette smokers’ vis-à-vis traditional cigarette smokers reveal almost similar cytotoxins delivery to the body systems by non-combustible e-cigarettes as those delivered by combustible cigarettes, including carcinogens such as carbonyls, heavy metals, nicotine, and tobacco-associated N-nitrosamines, as well as respiratory and cardiovascular malfunctioning.

Health Effects of E-cigarettes

The e-cigarette is an electronic simulation of tobacco smoking. Unlike a traditional cigarette, e-cigarette uses batteries to heat a non-combustible e-liquid made from tobacco products and flavor additives to produce an aerosol for e-cigarette vaping that simulates cigarette smoking. Accordingly, unlike combustible tobacco cigarettes, e-cigarettes deliver nicotine directly to the respiratory tract with no combustion. Non-combustibility of e-cigarette makes them less risky to user’s health than the risk posed by tobacco cigarettes. Furthermore, an e-cigarette offers users the option of controlling the ingredients in e-liquid aerosol than possible in tobacco smoking. In particular, e-cigarette gives users an option to include or exclude nicotine in the basic glycol and glycerol e-liquid content. In contrast, nicotine is the main ingredient in tobacco cigarettes. Similarly, e-cigarettes users have an option to include or exclude flavors into the basic e-liquid content. Proponents of e-cigarette cite such flexibility in e-cigarettes ingredients as the basis for its support as a healthier alternative to tobacco cigarettes whose ingredients are unalterable. Accordingly, some health experts recommend e-cigarette as a therapy for tobacco smoking cessation..

A couple of randomly controlled trials affirm health experts’ recommendation of the e-cigarette as healthier alternatives to tobacco cigarettes. For instance, Shahab et al. study on the disparity in nicotine, carcinogen, and toxin exposure between e-cigarettes, tobacco cigarettes, and nicotine replacement therapy reveals almost half fewer nicotine levels in non-combustible e-cigarettes users than the nicotine levels measures in combustible tobacco cigarette users (5). Similarly, Shahab et al. study reveals considerably lower levels of nicotine associated alkaloids, such as anatabine and anabasine in non-combustible e-cigarette users’ samples, than the level found in combustible tobacco cigarette smokers (5). Furthermore, Shahab’s study establishes lower levels of other cytotoxins in the e-cigarette and nicotine therapy users’ than the levels found in combustible tobacco cigarette smokers, including carcinogenic metabolites, such as 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) (5). Shahab et al. study also found the lowest level of acrylonitrilevolatile organic compound (VOC) metabolite in e-cigarettes users (5). In particular, Shahab’s study measured only half the level of urinary VOC metabolite in e-cigarettes and nicotine replacement therapy in users of the overall level of VOC metabolite found in combustible cigarette smokers’ urine (5). Such findings affirm healthcare experts support for e-cigarettes for tobacco cigarettes cessation therapy and mitigating health and social problems associated with smoking combustible tobacco cigarettes.

Although the substitute of combustible tobacco cigarettes with non-combustible e-cigarettes helps in the mitigation of cytotoxicity of tobacco smoking as confirmed by randomly controlled trial studies, e-cigarette still contains traces or equal levels of cytotoxins found in tobacco cigarettes. For instance, Shahab et al. confirmed the presence of all the cytotoxins found in urine or blood samples of combustible tobacco cigarette users in the e-cigarette users’ sample, albeit at a lower level (5). Such cytotoxins include nicotine and volatile organic compounds metabolites, such as NNALs. Similarly, Shahab et al. study show comparable levels of VOCs metabolites, such as muconic acid and benzene, stylene, phenylglyoxylic acid, and cysteine for both tobacco cigarettes and e-cigarettes smokers (5). The substitution of tobacco cigarettes with e-cigarettes, therefore, only mitigates but does not eliminate smoking-associated cytotoxins. Random controlled trials study cited in support of e-cigarette health benefits also does not demonstrate the extent to which lower levels of cytotoxins pose less serious health risks than the dangers associated with tobacco cigarettes. Similarly, comparable levels of cytotoxins, such as benzene, stylene, and phenylglycoxulic acid VOCs metabolites, pose similar cytotoxicity threats as those presented by tobacco cigarettes. E-cigarettes, therefore, does not eliminate health and social problem issues associated with tobacco smoking. At best, it only mitigates the problem to a level that researchers have not been able to empirically proof or quantify (Fairchild et al. 216). In particular, mitigation of cytotoxins levels does not automatically bestow health benefits unless they are empirically proved.

Utilitarian Merits of E-cigarettes

Utilitarianism ethical theory focuses on scientific or rational defense or criticism of an action or behavior as well as maximization of human pleasure and happiness or satisfaction (Cavico 24). Furthermore, utilitarianism is also a consequentialist paradigm in its rationalization of morality based on the consequences of a behavior or action. Utilitarianism disregards the nature of the action and instead focuses on its consequences to determine its morality (Cavico 24). Accordingly, if the action’s good outcomes exceed its bad results, it is considered as a moral action, but if its bad outcomes exceed its good results, it is considered an immoral action (Cavico 24). However, unlike ethical egoism, utilitarianism does not exclusively consider an action’s consequences on oneself, but also the larger groups, people, community, or the entire society (Cavico 24). Utilitarian analysis of e-cigarettes morality requires a focus on all stakeholders affected by e-cigarettes consumption, including smokers, non-smokers, minors, medical and public health community, lobby groups, e-cigarette manufacturers, and distributors and retailers.

The utilitarianism ethical paradigm supports e-cigarettes as ethical in their mitigation of bad consequences associated with tobacco smoking. In particular, e-cigarettes address the smoking problem as the leading cause of preventable death in industrialized countries. The utilitarian benefits of e-cigarettes include its use as a non-combustible substitute in smoking cessation therapy. Case studies of e-cigarettes smokers also confirm their utilitarian benefits in mitigating health risks associated with combustible tobacco cigarettes smoking. Such health benefits include the use of safe e-liquid ingredients, such as glycerine that is abundant in most foods as well as propylene glycol that is also safely used in the production of theatrical fog. Similarly, e-cigarettes give smokers liberty to mitigate the toxicity of an e-cigar by varying the nicotine solutions’ strength by completely excluding nicotine from e-liquid solution (Fairchild et al. 216). Additional utilitarian benefits of e-cigarettes over tobacco cigarettes include its long-term cheaper price, absence of cytotoxins such as arsenic, tars, and similar toxins associated with combustible tobacco cigarettes. The multitude of economic and health advantages of e-cigarettes over tobacco cigarettes explains its support by utilitarian ethicists, including healthcare experts, politicians, lobbyists, investors, and a section of the general public.

Utilitarian ethics requires looking on either side of the coin in the evaluation of the morality of an action rather than the focus on one side of the coin, as evident in proponents focus on the exculpatory merits of e-cigarettes without articulating incriminatory evidence that discredits e-cigarettes consumption. A wealth of randomly controlled trial studies and case study reports underscore equal negative health and economic effects of e-cigarettes to smokers. For instance, a starter pack of e-cigarettes that also include a charger, two batteries, and up to five nicotine holding cartridges costs $80, which is between 6 and 8 folds more than a pack of tobacco cigarettes (Cavico 25). An e-cigarette start-up-kit can cost up to $120, which is more than ten folds the cost of tobacco cigarettes (Cavico 24). Furthermore, e-cigarettes aggravate rather than mitigate smoking addiction social problems as indicated by industrial reports of e-cigarettes market. For instance, according to industrial reports, e-cigarettes industry grew to a $2 billion worth market in 2013 (Cavico 26). Similarly, Bloomberg Businessweek determined that e-cigarettes accounted for over half-trillion dollars industry in the world annually. Furthermore, Euromonitor International projected the growth of the world’s e-cigarettes market to a historical $5 billion work market in 2014 (Cavico 26). Likewise, e-cigarettes start-up-kit sales shot to 5 million devices in 2012 from 50,000 devices in 2008 (Cavico 26). The highlighted market trend of e-cigarettes consumption invalidates their support as smoking cessation therapy and instead underscores them as substitutes for tobacco cigarettes. In reality, the superior appeal of e-cigarettes over tobacco cigarettes aggravates rather than mitigating smoking addiction social problem and its associated health issues. Accordingly, utilitarianism scale does not support e-cigarettes consumption as moral action since they lead to equal or more negative economic, health, and social problems to smokers compared to those caused by tobacco cigarettes smoking.

The bad and good consequences of e-cigarettes consumption affect other stakeholders besides e-cigarettes smokers. For instance, e-cigarettes eliminate second-hand smoke associated with tobacco cigarettes and instead only expose them to cloud-like mist (Watson 1). However, e-cigarettes adverts lure non-smokers to e-cigarettes smoking and eventually into tobacco cigarettes smoking with serious negative health consequences (Watson 1). Likewise, media reports, such as the 2014 Miami Herald report shows worrying escalation of e-cigarettes smoking by minors in high school and middle school (Watson 1). Furthermore, CDC report shows that 90 percent of smoking lifestyle begins at teenage age, which underscores the risk of e-cigarettes trends on lifestyle health and social problems associated with smoking, whereby approximately 1.78 million teenagers and children indulge in e-cigarettes usage (Cavico 25). On their part, medical and public health experts cite medical studies, such as the Lancet British medical journal study report, to support e-cigarettes like tobacco cigarettes smoking cessation therapy (Watson 1). Likewise, proponent lobbyist supports e-cigarettes as a safer alternative to tobacco cigarettes, whereas opponents downplay safety of e-cigarettes (Hartmann-Boyce 1). On their part, e-cigarettes entrepreneurs are concerned with the maximization of profits from e-cigarettes sales with little concerns on their safety (Hartmann-Boyce 1). In the absence of scientific proof of e-cigarettes safety vis-à-vis tobacco cigarettes, most of the proponent support for e-cigarettes is based on ethical egotism arguments rather than realists utilitarian benefits of e-cigarettes.

E-Cigarettes Health Issues

E-cigarettes also have specific health issues than those associated with tobacco cigarettes smoking. For instance, Marcham and Springston associate e-cigarettes consumption with a multitude of negative side effects such as vomiting, respiratory irritation, dizziness, and nausea. Furthermore, although randomly controlled trial studies of e-cigarettes smokers reveal dissipation of some side effects in the long-run, some effects such as mouth and throat irritation persist in frequency and severity.

Randomly controlled trials studies also associate e-cigarettes smoking with similar health risks associated with tobacco cigarettes smoking. For instance, Vlachopoulos et al. study establish a similar increase in aortic stiffness and blood pressure after 30 minutes of e-cigarettes smoking, as witnessed after 5 minutes of smoking of tobacco cigarettes by young smokers (2802). In particular, Vlachopoulos et al. found heart rate increase by 3.1 beats/minute after 30 minutes of e-cigarettes smoking, which is comparable to the 4.0 beats/minute heart rate increase after 5 minutes of tobacco cigarettes smoking (2802). Similarly, Vlachopoulos et al. (2802) study found that both e-cigarettes and tobacco cigarettes elevated systolic blood pressure as well as diastolic blood pressure to comparable levels. Furthermore, Vlachopoulos reveals an increase in carotid-femoral pulse-wave velocity (PWV) by 0.36 m/s after 30 minutes of e-cigarettes smoking, which is comparable to the 0.44 m/s PWV increase after 5 minutes of tobacco cigarettes smoking (2803). Considering that young smokers smoke e-cigarettes for longer time and more frequently than tobacco cigarettes, as shown by the earlier highlighted industrial report, Vlachopoulos study established e-cigarettes as equal or more serious health risks for cardiovascular diseases as tobacco cigarettes (2802-2803). In particular, the study underscores a prognostic link between e-cigarettes associated with aortic stiffness and blood pressure increase, and later cardiovascular incidents and deaths. Similarly, randomly controlled trials studies affirm similar health risks effects of e-cigarettes as that posed by tobacco cigarettes. Accordingly, such revelation dismisses support for e-cigarettes as healthier substitutes to tobacco cigarettes.

Conclusion

Despite realist benefits of e-cigarette in mitigating health and social problems associated with cigarette smoking and in control of healthcare budget deficits, evidence-based research and randomly controlled trials reveal similar cytotoxicity threat of e-cigarettes to human health as that posed by traditional cigarette smoking. E-cigarettes somewhat mitigate but do not eliminate social and health problems associated with tobacco cigarette smoking, such as cytotoxity risks and cardiovascular disease threats or substance abuse social problems. In light of this, doctors should not advise patients to switch to e-cigarettes.

Works Cited

Cavico, Frank.  J, et al. “E-Cigarettes: An Unfolding Legal, Ethical, and Practical Quandary.” Journal of Psychology and Behavioral Science, vol. 2, no. 2, 2014, pp. 01–44.

Fairchild, Amy L., et al. “E-Cigarettes and the Harm-Reduction Continuum.” New England Journal of Medicine, vol. 378, no. 3, 2018, pp. 216–219.

Hartmann-Boyce, Jamie. “Why Can’t Scientists Agree on e-Cigarettes?” The Guardian, Guardian News, and Media, 14 Sept. 2016, www.theguardian.com/science/sifting-the-evidence/2016/sep/14/why-cant-scientists-agree-on-e-cigarettes-vaping.

Health & Wellbeing Directorate, Public Health England. “E-Cigarettes: a New Foundation for Evidence-Based Policy …” Heartland Institute, 1 Aug. 2015, assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/454517/Ecigarettes_a_firm_foundation_for_evidence_based_policy_and_practice.pdf.

Marcham, Cheryl L., and John P. Springston. “Electronic cigarettes in the indoor environment.” Reviews on environmental health, vol. 34, no. 2, 2019, pp. 105-124.

Shahab, Lion, et al. “Nicotine, Carcinogen, and Toxin Exposure in Long-Term E-Cigarette and Nicotine Replacement Therapy Users.” Annals of Internal Medicine, vol. 166, no. 6, 2017, pp. 390–395.

Vlachopoulos, Charalambos, et al. “4.3 Electronic Cigarette Smoking Increases Aortic Stiffness In Young Smokers.” Artery Research, vol. 67, no. 23, 2016, pp. 2802–2803.

Watson, Stephanie. “E-Cigarettes: What the Research Shows.” WebMD, WebMD, 19 Mar. 2014, www.webmd.com/smoking-cessation/news/20140326/what-research-shows-about-e-cigarettes.